Best Care May Be at Hospitals That Spend Most

In Ontario, hospitals that spent the most provided the best patient outcomes, researchers found.

Action Points

This study indicates that among Ontario hospitals higher hospital costs are associated with higher intensity of care and are associated with better clinical outcomes.

Note that editorialists from Harvard School of Public Health suggested that although it's unclear whether the findings can be applied to U.S. healthcare systems, it appears that the data is strong enough that they may be.

In Ontario -- which has a universal healthcare system -- hospitals that spent the most provided the best patient outcomes, researchers found.

Patients with various conditions treated at hospitals in the highest third of spending intensity had lower rates of 30-day and one-year mortality, readmission, and major cardiac events, according to Therese Stukel, PhD, of the Institute for Clinical Evaluative Sciences in Toronto, and colleagues.

Those patients were also more likely to receive evidence-based care, the researchers reported in the March 14 issue of the Journal of the American Medical Association.

"This study shows that in Ontario, a province with global hospital budgets and fewer specialized healthcare resources than the U.S., outcomes following an acute hospitalization are positively associated with higher hospital spending intensity," the authors wrote.

"Higher spending intensity, in turn, is associated with greater use of specialists, better patient care, and more use of advanced procedures," they continued. "These results suggest that it is critical to understand not simply how much money is spent but whether it is spent on effective procedures and services."

Stukel and colleagues examined data from adults in Ontario with a first admission for an acute MI (179,139), congestive heart failure (92,377), hip fracture (90,046), or colon cancer (26,195) from April 1998 through March 2008. All were followed for one year.

The researchers categorized the hospitals at which the patients received treatment as having low, medium, or high spending intensity based on how much the centers spent on patients in their last year of life.

At baseline, illness severity among patients with each condition did not vary based on the hospitals' spending intensity.

In general, patients treated at higher-spending hospitals had longer lengths of stay, a lower likelihood of being admitted to the intensive care unit, and more specialist visits and nursing care.

The patients with MI who were treated at higher-spending facilities were more likely to undergo cardiac interventions, to receive evidence-based discharge medications, to have collaborative ambulatory care within four weeks, and to visit with a cardiologist within a year.

Those with heart failure were less likely to receive contraindicated drugs, and those with hip fracture were more likely to receive inpatient rehabilitation if they were treated at a higher-spending hospital.

Patients with colon cancer were more likely to have preoperative specialist consultation if they were treated at one of the top-spending institutions.

In addition to receiving higher quality care, patients admitted to hospitals with the highest spending intensity had lower rates of all adverse outcomes compared with those admitted to hospitals in the lowest-spending category.

For example, the 30-day mortality rate for acute MI was 12.7% in the highest-spending hospitals versus 12.8% in the lowest-spending. For congestive heart failure the rates were 10.2% and 12.4%, for hip fracture rates were 7.7% and 9.7%, and for colon cancer they were 3.3% and 3.9%.

The results were similar for one-year mortality, readmissions, and major cardiac events (for patients with acute MI and congestive heart failure).

Increasing spending at the lower-spending hospitals, however, will not necessarily improve patient outcomes, Stukel and colleagues noted.

"Higher-spending hospitals differed in many ways, such as greater use of evidence-based care, skilled nursing and critical care staff, more intensive inpatient specialist services, and high technology, all of which are more expensive," they wrote.

In an accompanying editorial, Karen Joynt, MD, MPH, and Ashish Jha, MD, MPH, of the Harvard School of Public Health in Boston, added that the nature of a hospital's mission could also influence outcomes.

"Features that make a hospital high cost, such as a teaching mission or research mission, may actually be related to better outcomes," they wrote. "Thus, it is possible that it was not spending per se that improved outcomes but rather the teaching intensity or academic expertise more common at high-cost hospitals."

They noted that it is unclear whether the findings can be applied to U.S. healthcare systems.

"Yet it appears that they may be, given the strength of the data and the consistency of the findings with emerging U.S.-based work in this area," they wrote.

Stukel and colleagues acknowledged that the study was limited by the inability to identify specific components of care that are associated with better outcomes, the inability to rule out the possibility that higher-spending hospitals coded more aggressively, and the uncertain generalizability of the findings to chronic conditions.

Funding was provided by an Emerging Team Grant in Applied Health Services and Policy Research from the Canadian Institutes of Health Research, by a grant from the U.S. National Institute on Aging, and by the Institute for Clinical Evaluative Sciences, which is funded by an annual grant from the Ontario Ministry of Health and Long-Term Care.

The study authors and the editorialists reported that they had no conflicts of interest.

Reviewed by Zalman S. Agus, MD Emeritus Professor, Perelman School of Medicine at the University of Pennsylvania and Dorothy Caputo, MA, RN, BC-ADM, CDE, Nurse Planner

MedPageToday is a trusted and reliable source for clinical and policy coverage that directly affects the lives and practices of health care professionals.

Physicians and other healthcare professionals may also receive Continuing Medical Education (CME) and Continuing Education (CE) credits at no cost for participating in MedPage Today-hosted educational activities.